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In looking at current program designs, Dr. Silberman noted that some States have capitated or PCCM programs statewide
and other States allow different programs in rural and urban areas (i.e., PCCM in most of the State with some capitation
limited to urban areas; capitation programs operating in most of the State and certain rural areas operating PCCM or
partial capitated programs; capitation programs available in both urban and rural areas but mandatory capitation limited to
urban areas).

The results seem related to barriers to statewide capitation such as the lack of commercial health maintenance organizations (HMOs) in rural
areas and lack of providers or provider resistance to managed care arrangements.

Dr. Silberman reviewed various State
strategies for overcoming these barriers such as changing their goals and using phased-in approaches, expanding the
definition of primary care providers, and engaging in extensive community education efforts to reduce provider resistance.

Also discussed was how States vary in their protections for so-called safety-net providers, (e.g., community health centers)
from no or minimal protections to giving managed care organizations (MCOs) extra points for contracting with safety-net providers or actually
mandating contracts with certain safety-net providers.

Missouri is an example of a full-risk State. Ms. Irwin discussed various functional aspects of that program such as rural
access standards. For example, the PCP (primary care provider) 20-mile standard cannot apply in rural areas where the
usual and customary is a greater distance. Usual and customary is based on a commercial market standard for the area.